Dictation Best PracticesDictation Best Practices

A Guide for PhysiciansA Guide for Physicians

Dictation Best PracticesDictation Best Practices

A Guide for A Guide for PhysiciansPhysiciansPresented

by the

American Association for Medical Transcription

Sponsored by

Why Do You Dictate?Why Do You Dictate?

Documentation is an Essential Ingredient of Good Medical

Care

Good DocumentationGood Documentation

Accurate Complete Available When Needed

Quote or QuillQuote or Quill

Dictation is an effective and economical way to

convey the patient’s story

The ChallengeThe Challenge

Communicate clearly and succinctly

Partners in QualityPartners in Quality

Medical Transcriptionists are documentation experts and your partner in creating the required record of care—accurately and efficiently.

Impact of DictationImpact of Dictation

Documentation errors Patient Safety Sentinel Events Turnaround Time Costs

Patients at RiskPatients at Risk

Poor dictation can result in the omission of very important words such as “no” or “non”, as in “there is (no) malignancy identified”

US Leads in Medical US Leads in Medical ErrorsErrors

“Thirty-four percent of U.S. patients received wrong medication, improper treatment or incorrect or delayed test results during the last two years, the Commonwealth Fund found.”

US Leads Way in Medical Errors, S. Heavy, Common Dreams, November 23, 2005

View of the CourtsView of the Courts

According to the Wisconsin Supreme Court

“We hold only that hospital records bear such an unusual indicia of reliability and trustworthiness that … such records satisfy the confrontation clause.”

Good DictationGood Dictation

Improves communication among caregivers

Promotes patient safety Reduces turnaround time from

dictation to charting Ensures uncompromised reports

as legal documents

Poor DictationPoor Dictation

Leads to errors in transcription Puts patients at risk Slows and/or reduces

reimbursement Impacts timely delivery of care Increases administrative and

transcription costs

Problematic DictationProblematic Dictation

Incorrect verbiage or grammar Rapid speech English as a second language Articulation Insufficient volume Background noise Incorrect or insufficient patient

information

Turnaround TimeTurnaround Time

Quality patient care demands shorter turnaround time

Problematic dictation can double or triple time spent transcribing

Several problematic reports can affect timely delivery of all reports

CostsCosts

Inferior dictation increases administrative costs

Inadequate dictation decreases or delays reimbursement

Poor dictation can increaseturnaround time, delaying treatment

DictationDictation

Requires special attention to clarity and style

No visual clues (lip movements, facial expressions)

Asynchronous communication Lacks flow and rhythm of

conversations More difficult to comprehend

Speech RecognitionSpeech Recognition

Realizing higher adoption rates Incapable of completely

replacing transcriptionists Unable to interpret vast majority

of dictators Requires more attention to

organization and articulation

EnvironmentEnvironment

Monitor background distractions such as voices, telephone ringing, and/or music

Avoid side conversations

Background NoiseBackground Noise

He had three recent _____ procedures and is seeing a cardiologist.

OrganizationOrganization

Organize data before dictating

Follow established templates

Disorganized DictatorDisorganized Dictator

Chest wall showed tenderness on pressing on the right lateral and anterior ribs area. Back showed kyphosis. Heart S1, S2.

EquipmentEquipment

Refer to tip sheets for proper use of dictation equipment

Use correct hand-held settings to avoid clipped words

Hold the mic the proper distance from the mouth

Too Close to MicrophoneToo Close to Microphone

At that time, her chest x-ray ____ a new finding of ______ atelectasis which I felt was due to her residual RSV bronchiolitis.

““Puffing” the MicPuffing” the Mic

Babinski and no clonus ____ in the upper and lower extremities. Her motor is normal. Her sensation is decreased in the C6 distribution on the left. She does have a positive Tinel sign over the median nerve but a negative Phalen sign.

DemographicsDemographics

Key identifying information when prompted

State and spell the patient’s name

Include at least one other patient identifier (i.e., birth date or MRN)

State the date of service

CourtesyCourtesy

Avoid eating and chewing gum

Pause while yawning, coughing or sneezing

Remember! We can hear what you wouldn’t want us to hear!

YawningYawning

Back pain ____________. Past medical history is negative. Surgery negative.

SpeechSpeech

The dictator’s speed and poor articulation were cited as being the most frequent causes of problematic dictation.

Key SyllablesKey Syllables

“No” or “known” ABduction or ADduction

hyPO or hyPER

AbbreviationsAbbreviations

Avoid uncommon abbreviations Use abbreviations from facility’s

approved list Give clues when dictating

common abbreviations BMP versus BNP CNS versus C&S

NumbersNumbers

Dictate numbers clearly and succinctly

Differentiate “fifty” and “sixty” (e.g. five-oh, six-oh)

Delineate vital signs and lab values with test names

Running Numbers Running Numbers TogetherTogether

Temperature is 98.3, 120/60, 105, 16.

MedicationsMedications

Carefully dictate medication names and dosages, especially those with sound-alikes

(e.g. Endal, Inderal; MiraSept, Mircette)

FeedbackFeedback

Return notations on blanks or incorrect areas of the document to the transcription staff in order to prevent errors in the future

Dictation Tool KitDictation Tool Kit

Dictation Fact Sheet Dictation 101 Model Policies and Procedures Sample Q Cards Feedback Letter Tip Sheet

www.AAMT.orgwww.AAMT.org

The Bottom LineThe Bottom Line

Good quality dictation and transcription is win-win for the patient, the caregiver, and the facility’s bottom line

ContactContact

American Association for Medical American Association for Medical TranscriptionTranscription

www.aamt.orgwww.aamt.org

800-982-2182 800-982-2182

MedQuist is the leading provider of clinical document workflow solutions. MedQuist provides document workflow management, digital dictation, speech recognition, dictation devices, Web-based transcription, electronic signature, medical coding and outsourcing services.

MedQuist Inc. Corporate Offices

1000 Bishops Gate Blvd.Suite 300

Mount Laurel, New Jersey08054-4632

Phone: 800-233-3030 Fax: 856-206-4020

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